Miller et al from the United States reported on an important study comparing an endoscopic and a medical approach in treating acute intracerebral hematomas. In a small 10-patient randomized study, the authors used endoscopic removal of the hematomas within 24 hours of the onset of symptoms. Endoscopic removal produced an 80% reduction in hematoma volume and 20% mortality, whereas medical management resulted in a 78% increase in volume with a 50% mortality. This is a very convincing study but needs to be repeated on a larger scale to confirm its conclusions. If so, it would be a landmark advance in the treatment of ICH. Read Auer's comments at the end. He pioneered the endoscopic approach almost 20 years ago.
Hernesniemi et al from Finland have written another outstanding article on the technical approach to colloid cysts of the third ventricle. This is worth reading from its thorough discussion of the anatomy and to the technical aspects of surgery. I have written some comments at the end from my experience. Of note, in an update of my comments, Bergsneider has now abandoned the endoscopic low frontal approach parallel to the lateral ventricular floor to see the attachment of the colloid cyst to the roof of the third ventricle through the Foramen of Monro in favor of a transcortical direction through a plastic sleeve in the manner of Pat Kelly.
Hamilton et al from the United States studied 55 patients between the ages of 46 and 96 who had spinal stenosis and back pain with radicular symptoms without claudication. Of 55 patients, 46 had spondylolisthesis of less than 25%, and 11 had no slippage. Decompressive laminectomies were followed by bony fusion with local spinous processes as the bone graft material and bone morphogenic protein. The patients were severely disabled before surgery (Table 4) but showed marked improvement with the procedure. The disability differentiates this population from those with spinal stenosis and less symptoms. I like the idea of this type of biochemically induced fusion in those who need a fusion at this age level. This is not too bad an idea for younger people either. Read the comments from multiple experts at the end. Chris Abood suggests that the disease can be treated with newer minimally invasive techniques. The real question is, do these people need a fusion at all? As mentioned above, this selected population may have been severely disabled with pain to justify that choice. It would be very worthwhile if the authors could do the next series comparing the standard laminectomy with a laminectomy and bone morphogenic protein augmented fusion. This would be a major contribution to the literature to supplement this study.
Gilbert et al from the United States discussed a case report in which a woman presented with cervical radiculopathy was unresponsive to medical management and with negative imaging studies. With upright functional and positional magnetic resonance imaging to produce the symptoms, they were able to demonstrate pathology not seen in the neutral position. Read reference 14 by Vitar, which analyzes their results in 20 patients. Reference 3 is another case report by the authors with limited literature review. The technique of upright dynamic magnetic resonance that has been around for some time seems to be of value. Interestingly, there is little written about it.
Prestor et al from Slovenia described the use of somatosensory evoked potentials from the dorsal spinal cord to determine the site of the myelotomy they used for insertion of a syringo-subarachnoid shunt. The abstract is the best place to start followed by the Introduction and then Sandi Lam's excellent analysis of this article. The idea of performing the myelotomy at the root entry zone or the midline depending upon what nerve fibers are damaged seems reasonable, but Lam's comments reveal a far more complicated background to this thinking. Her idea of a longer follow-up to determine the delayed complications seems reasonable.
Mohindra et al from India wrote a simple but very thoughtful article on the outcomes of head injury in the elderly patients (older than 70 years). The authors point out that none of the 45 patients followed had a good outcome; most had severe injuries, more than one half had SDH or contusions, all of which required surgery in 45 cases. Mortality was 66%. In a comparable group of 1026 younger patients aged 20 to 40 undergoing surgery, there was a 28% mortality. The discussion is illuminating scientifically and philosophically. They suggest that results such as these encourage a nihilistic approach for older patients. They describe the comorbid conditions that can compromise the outcomes in older patients such as larger hematomas (probably because cerebral atrophy allows room for hematoma expansion), delays in diagnosis, other disease states, greater sensitivity to ischemia, and impaired regeneration as possible contributors to the compromised outcomes. In their conclusion, they rightfully suggest that prevention of traumatic injury in older people may be better than salvage. They note that the “support of the family” may be critical. Oriental cultures seem to have a greater regard for the family than is now occurring in many Occidental countries as industrialization and globalization occur, but there are less resources to support those efforts if a family member becomes ill. Read my editorial on “Nihilism and aging in medicine.”
Sonobe et al from Japan reported on their single institution experience with the coiling of 247 ruptured cerebral aneurysms. Aneurysms between 2 and 15 mm with a definite neck were coiled. Those with difficult anatomy, atherosclerosis, or ICH were subjected to clipping. For those patients with thick SAH, spinal drainage was begun before coiling, and TPA was infused through the spinal drain after coiling. The rate of vasospasm in this population was 13% as compared with 22% in the literature. Mortality and morbidity were below 5%. Rebleeding occurred in 8 patients, which seems high to me and suggests that “tighter packing” of coils, initially, might be the answer to prevent this rebleeding. According to Saito's comments, this study is one of the early large interventional reports with coiling in Japan. For a group of excellent neurosurgeons, like the Japanese, who are more reluctant to accept interventional approaches to aneurysms, this study from Japan is a real landmark signaling change to come.
Cosar et al from Turkey have done a nice study on the effects of temporary aneurysm clipping on the common carotid artery wall of atherosclerotic and nonatherosclerotic rabbits. The authors discovered that temporary clipping of the arterial wall in nonatherosclerotic rabbits only produced endothelial damage after 10 minutes. Atherosclerotic animals developed wall damage 1 minute after clip application. This article is well done, and the message is clear. Use shorter temporary clip times.
There are 2 articles on intracranial aspergillosis. The first by Akhaddar et al from Morocco is an excellent case report. Mohindra et al from India reported on a series of 46 patients with this disease. Together, these two articles plus the comments at the end provide an excellent summary of this disease and its management.
Mandl et al from the Netherlands reported a study of repeat surgery with or without chemotherapy and/or radiation or radiation alone for recurrent glioblastomas. In this selected series, the authors found that surgery with chemotherapy or radiation will produce the longest survival followed by radiation therapy or chemotherapy alone without surgery. Surgery alone was the least effective treatment. They conclude that the role of repeat craniotomy is limited only to tumors producing a mass effect. Harry Cole's comments at the end hit the mark. (What happened to good surgical judgment like Harry's? We need more of this type of thinking.) The patient does not care about statistics; the patient wants extra time with their family or has other personal reasons for survival that are none of the doctor's business. Our job is to help our patients achieve what they want in life. It is not a physician's position to deny treatment. (Governments do that!) We are to offer informed alternatives to the patient so that he or she can decide what to do with their life. Whose life is it anyway?
Ron Pawl, one of Surgical Neurology's pain experts has written an editorial on the reasons for the overuse of narcotic medication for chronic nonorganic pain syndromes. This article is extremely well written, as usual for Ron, and should be read.
Are we guilty of letting older people die because they are older? Well, “they are old” is commonly heard in Medicine. Are we biased against older people so that we do not treat them aggressively? What is the evidence for this belief? Read my editorial on “Therapeutic nihilism and the elderly.”
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